1. Field of the Invention
The present invention relates generally to medical methods. More particularly, the present invention provides improved methods, apparatus, and kits for establishing access to a patient""s vascular system for hemodialysis and other extracorporeal blood treatments.
Access to a patient""s vascular system can be established by a variety of temporary and permanently implanted devices. Most simply, temporary access can be provided by the direct percutaneous introduction of a needle through the patient""s skin and into a blood vessel. While such a direct approach is relatively simple and suitable for relatively short procedures, such as intravenous feeding, intravenous drug delivery, and the like, they are not suitable for hemodialysis, hemofiltration, or other extracorporeal procedures that must be repeated periodically, often for the lifetime of the patient.
For hemodialysis and other extracorporeal treatment regimens, a variety of transcutaneous catheters and implantable ports have been proposed over the years. Transcutaneous catheters, such as the Tesio catheter available from Med Comp and the Perm-Cath(trademark) available from Quinton, comprise a single catheter tube having a distal end placed in a vein in an in-dwelling manner and a proximal end which extends through the skin and which is available for connection to a hemodialysis or other blood treatment system.
Implantable ports, in contrast, are entirely subcutaneous and connect to a vein or an artery by a subcutaneous xe2x80x9cconnectingxe2x80x9d cannula. Access to the port is achieved by percutaneous placement of a needle or other connecting tube. Such ports typically comprise a needle-penetrable septum to permit percutaneous penetration of the needle. Recently, several valved-port designs have been proposed, where percutaneous introduction of a needle or other access tube into the port opens the valve to permit flow to or from the cannula which connects to the blood vessel.
While both port-access and transcutaneously implanted cannula systems have enjoyed varying levels of success, they continue to suffer from certain disadvantages and limitations. For example, placement of both the port-access and transcutaneously implanted cannula systems has been problematic. Methods and systems for establishing vascular access have been described in related co-pending applications Ser. Nos. 09/333,828; 09/333,728; and 08/856,641, now U.S. Pat. No. 5,931,829, assigned to the assignee of the present application. Typically, such systems place a draw catheter, to draw blood out of the body, proximally of a return catheter, which returns treated blood to the body. Both catheters may be placed through the superior vena cava with the draw catheter tip in the superior vena cava and the return catheter tip extending to a junction between the superior vena cava and the right atrium. However, such access protocols can occasionally result in recirculation of returned treated blood back into the draw catheter. Additionally, such access methods permit only limited blood flow rates. Such limited blood flow rates are problematic since they prolong the duration of the associated extracorporeal blood treatment protocol, such as hemodialysis, hemofiltration, plasmapheresis, apheresis, and the like. Moreover, limited flow rates may cause possible catheter blockage or plugging resulting from fibrin sheath or thrombosis formation over the distal end of the catheter.
For these reasons, it would be desirable to provide improved methods for establishing access to a patient""s vascular system for hemodialysis and other extracorporeal blood treatments. In particular, it would be desirable if such improved methods could provide enhanced flow rates without increasing a lumen diameter of the catheters, reduce instances of fibrin sheath or thrombosis formation, and minimize the recirculation of already treated blood. It would be further desirable if such improved methods were useful with both port-access and transcutaneous access systems for hemodialysis, hemofiltration, and other extracorporeal treatment systems. At least some of these objectives will be met by the methods of the present invention described hereinafter.
2. Description of the Background Art
U.S. Pat. No. 5,718,692 describes a double catheter assembly where each catheter has side holes at its distal end. U.S. Pat. Nos. 5,562,617 and 5,041,098 are exemplary of implantable systems employing cannulas extending between a port and a blood vessel for providing extracorporeal circulation. U.S. Pat. Nos. 5,417,656 and 5,281,199 show implantable ports which are connected to vascular cannulas via a transition region (FIG. 1A) and to a multiple branch cannula (FIG. 21). U.S. Pat. No. 4,892,518 shows an implanted port with a transition region extending to a cannula. U.S. Pat. Nos. 5,234,406 and 5,215,530 show two-piece catheters having a distal portion which can be placed percutaneously. The ""406 patent discloses a large diameter proximal portion to enhance the flow rate of anesthetics to the subarachnoid region of the spine. U.S. Pat. Nos. 5,203,771 and 4,181,132 show implantable connectors which provide for percutaneous access to implanted shunts.
Related co-pending applications, assigned to the assignee of the present application, include Ser. Nos. 09/630,362; 09/333,828; 09/333,728; 09/238,523; 08/942,990, now U.S. Pat. No. 6,007,516; 08/856,641, now U.S. Pat. No. 5,931,829; 08/745,903, now U.S. Pat. No. 5,755,780; 08/724,948, now U.S. Pat. No. 6,053,901; 08/634,634, now U.S. Pat. No. 5,713,859; 08/539,105, now U.S. Pat. No. 5,807,356; and 60/036,124.
The full disclosures of each of the U.S. patents and co-pending applications listed above are hereby incorporated herein by reference.
The present invention provides improved methods for establishing vascular access to a patient""s body lumen or other target location, particularly coronary blood vessels and cavities, for performing extracorporeal treatment on circulating blood. Exemplary extracorporeal treatment procedures include hemodialysis, hemofiltration, hemodiafiltration, plasmapheresis, apheresis, and the like. In particular, the present invention provides improved methods and kits which enhance extracorporeal blood flow rates, reduce instances of fibrin sheath or thrombosis formation, and minimize recirculation effects. The present invention is most advantageous with access systems comprising a pair of implantable ports connected to a pair of connecting catheters, usually a draw catheter and a return catheter. Specifically, one of the connecting catheters will be intended as a xe2x80x9cdrawxe2x80x9d catheter for removing blood from the patient""s vasculature while the other of the catheters will be intended as a xe2x80x9creturnxe2x80x9d catheter for returning treated blood to the patient.
According to a first aspect of the present invention, methods for recirculating blood to a patient generally comprise placing a draw catheter so that a distal tip thereof is positioned in a right atrium of the patient""s heart. A return catheter is placed so that a distal tip thereof is positioned in a superior vena cava. Extracorporeal blood flow from the draw catheter to the return catheter may be established. Such methods are particularly useful in that they enhance extracorporeal blood flow rates by placing the draw catheter in the right atrium so that the pressure in the right atrium assists to draw increased volumes of blood through the draw lumen. Such high volume extracorporeal treatment protocols typically provide extracorporeal blood flow rates above 200 ml/minute, usually rates above 300 to 350 ml/minute, and preferably rates above 400 ml/minute or higher. Moreover, the increased blood flow resulting from the increase in pressure (provided by the right atrium) serves to wash a distal tip of the draw catheter which in turn reduces the occurrence of fibrin sheath or thrombosis formation from completely occluding the tip of the catheter, and thereby reducing the risk of trauma.
The placement steps preferably comprise passing the draw catheter and the return catheter both into the superior vena cava, with the draw catheter extending beyond a distal end of the return catheter. A draw lumen is disposed at a distal end of the draw catheter. The draw lumen will typically be disposed distally of the distal end of the return catheter by a distance in the range from 5 cm to 10 cm, preferably being in the range from 5 cm to 8 cm, and more preferably by a distance of 6 cm. Such access protocols of placing the draw catheter distal of the return catheter in the right atrium prevents and/or minimizes recirculation of returned treated blood as the drawn blood is now returned to a location in the superior vena cava. This in turn increases the efficacy in performing extracorporeal treatment on circulating blood.
The draw catheter and the return catheter may generally comprise tubular bodies having substantially uniform diameters over their entire lengths. Usually, the tubular bodies of the catheters will comprise elastomeric materials, such as latex, silicone rubber, polyurethane, or the like. The catheters will usually (but not necessarily) have a uniform inside diameter along their entire length, typically being in the range from 1 mm to 15 mm, usually being in the range from 2 mm to 5 mm. The lengths of the catheters will usually be in the range from 15 cm to 100 cm, preferably being in the range from 20 cm to 40 cm. While it is preferred that each of the two or more catheters be identical in all respects, in order to simplify manufacturing and maintenance, the catheters may also be non-identical. For example, the cannulas may comprise different distal end configurations, as described in more detail below, or alternatively may have different lengths. Either or both of the catheters may also be trimmed to length during implantation so that each of the catheters is sufficiently long for the intended use.
Both ends of each of the draw and return catheters should also be adapted in all respects for implantation within the blood vessel or other target body lumen or location. For example, it is strongly preferred that the distal ends of each of the catheters be chamfered or beveled in order to reduce the risk of trauma when implanted within a blood vessel. In this way, both ends of each catheter are ready for implantation within a blood vessel without modification or other preparations. Furthermore, the distal end of either or both the draw catheter and the return catheter may be modified to have flow diffusers. For example, a plurality of side holes may be formed integrally or otherwise formed in or attached to the catheter at or near the end. Optionally, the end portion may be modified to form a single back hole or xe2x80x9cbackeyexe2x80x9d configuration. Still further, the end portion may be modified to form a V shaped end or xe2x80x9cfish mouthxe2x80x9d configuration. Such flow diffuser configurations serve to maintain flow if the distal tip of the draw or return catheter is positioned against the wall of the blood vessel or other target location. Additionally, the end portions of either or both of the catheters can be angled in order to further minimize the impact of fibrin sheath or thrombosis formation from completely occluding the tip of the catheter, thereby reducing the risk of trauma when implanted in a blood vessel.
The draw and return catheters may be formed together over at least a portion of their lengths so as to form a dual lumen catheter. Alternatively, the draw catheter and return catheter may be separately formed over their entire lengths so as to form two single lumen catheters. Additionally, proximal portions of either or both the draw catheter and the return catheter may have intermittent moveable rings. These intermittent rings about the catheters usually provide accurate placement of subcutaneous cuffs which become ingrown in tissue for permanent or temporary fixations of such access systems.
The establishing extracorporeal blood flow step preferably comprises percutaneously accessing a pair of implanted ports which are connected to the draw catheter and the return catheter. Usually, each port includes an inlet aperture adapted to receive an access tube and an outlet connector. The outlet connector on each port will usually comprise a male fitting so that the draw or return catheter may simply be placed over the fitting. The placement steps may occur either before or after the catheters are connected to the ports. Alternatively, extracorporeal blood flow may be established by connecting transcutaneous proximal portions of the draw catheter and return catheter to an external pump, or to other external catheters (which may optionally have different sizes, characteristics, etc.) for transcutaneous access.
In another aspect of the present invention, an improved method for recirculating blood to a patient generally comprises passing a draw catheter and a return catheter into a superior vena cava. The draw catheter is placed beyond a distal end of the return catheter for establishing extracorporeal blood flow from the draw catheter to the return catheter. In such a configuration, the distal end of the draw catheter is disposed distally of the distal end of the return catheter by a distance in the range from 5 cm to 10 cm.
The present invention further includes kits comprising a draw catheter, a return catheter, and instructions to use the draw catheter and the return catheter to recirculate blood to a patient. Instructions for use will generally recite the steps for performing one or more of the above described methods. The instructions will often be printed, optionally being at least in-part disposed on packaging. The instructions may alternatively comprise a videotape, a CD-ROM or other machine readable code, a graphical representation, or the like showing any of the above described methods. The kit components will be packaged in a conventional medical device package that is usually sterile, such as a pouch, tray, tube, box, or the like.